PRP injection

[paula f3]

Our administrator has brought up a question to our billing department. I code for an ASC.
One of our orth physicians would like to peform the PRP injection at the same surgery session Through the information that I have gathered I am understanding that this would be considered inclusive with the surgery and we would not bill the PRP injection.
My admisistrator is inquiring that could we have the patient pay up front, have them sign
a ABN, if Medicare, and for private insurance have the patient sign waiver, would this something we should consider ?
I would appreciate any input from coders on the ASC side.
Thank you
Paula

[lingaraja]

Hi,

I am Lingaraj and I have 8 years of experience in coding for ASC setting.

Yes. PRP injections will not be paid if it is done in the same surgical session. Also it will not get paid if done with larger reconstruction procedures as it is considered to be inclusive of it.

It is advisable to sign a ABN or similar kind of Waiver with the patient.

[maryc@trgltd.com]

Good morning!

In recent times, many different ortho surgeons are employing PRP with a variety of other repair and reconstructive procedures (spine, total joint, arthroscopy, etc.). As a result, I think your question will be around many years to come. I believe there are really two issues here: physician use and facility supply payment.

For the physician, they need to be able to point to AT LEAST one journal article or publication demonstrating that the use of PRP is likely to have improved outcomes for THIS patient based on their dx. IF that clinical support is available, then it is likely that the facility may be able to recover the supply item fee from the patients' payors. It'll be under an appeal, but it may be the "right" path to change the payor mindset where this has not been payable at the outset.

As the other commenter indicated, CMS has indicated that PRP is not a payble service or supply item as it is considered "not medically necessary". This denial reason is why the physician needs to cite a publication in order for the facility to have a chance of being paid on the supply item.

Lastly, yes I believe that CMS-131-R (the current ABN form) or it's like would be appropriate if the patient agrees to pay out of pocket for the supply item. Note that OPTION 1 allows the patient to be financially responsible, but also allowing the submission to the payor. Be careful in that normally the PRP is charged per UNIT, and CMS-131-R needs to state the patient balance due to within $50 -- so the form should be completed with care and have the correct rationale for why payors are not expected to be responsible for the cost.